Part 1 of this paper (Food and Nutrition Bulletin,
vol. 11, no. 4, pp. 38-63) presented some of the background on
the real constraints in time, productive opportunity, and health
and nutrition that poor women face in their daily lives. It
showed that the cultural, economic, and biological limitations
placed on such women preclude their being as healthy and as
productive both economically and socially as they might be if
they had access to adequate resources. Four particular classes of
interventions are likely to reduce the constraints against
women's improving their nutritional situation: (1) increasing
women's income and control of income and productive resources,
(2) reducing their child-care burden, (3) increasing their
productivity in household production, and (4) improving their own
health and nutrition directly.

The logic is as follows: Women's income generation leads to
greater control over income, which in turn leads to expenditure
patterns favouring nutrition. On the other hand, women's
income-generating work diverts time from child care and other
household production to the money-making activities. The net
impact of increased income and decreased maternal child-care time
is a function of the quality of substitute child care. Hence,
adequate child care is an important intermediary between women's
economic participation and child welfare. Women's home production
activities require large amounts of time that might be better
spent on economic opportunities, child care, or rest.

Poor maternal health and nutrition diminish women's strength
and efficiency in market, household, and child-care spheres and
adversely affect reproductive outcomes. Improving women's
nutritional status should improve their health and increase their
productivity in household as well as market activities.

What follows is a review of programmes and policies shown to
create a positive-sum game by addressing these four issues.

Increasing women's income and control of income

Inadequate productive resources and too few basic consumption
goods are major determinants of undernutrition in developing
countries. At any given level of poverty, however, the
nutritional efficiency of resources within the household depends
on income control, time allocation, intrahousehold food
distribution, and the abilities and skills of those who provide
nutrition-enhancing services (cooking, breastfeeding, health care
and hygiene, child care).

One way of increasing women's economic influence within the
poor household is through increasing their participation in
income-producing activities [1]. This tactic has been the focus
of most "women in development" efforts. However,
economic activities can compete with production of goods and
services for home use. The net effect of greater income and
control of expenditures and reduced home-production time will
depend on the returns to women's labour and the quality and
affordability of available mother substitutes.

Agricultural productivity

Woman farmers

To increase productivity, women farmers need access to
agricultural extension, credit. land and livestock, labour, and
technology. The benefit from increased agricultural productivity
derives from sales and consumption of goods produced. To assure
that women benefit requires a careful gender analysis as part of
problem identification and programme decision. While men can
appropriate women's labour for their crops, women cannot
necessarily do the opposite. Since men's responsibilities may not
include supplying the household with food, increasing household
income can increase women's workload, reduce their control of
income, and adversely affect household food supply [2-6].

At present, agriculture extension is far more likely to reach
men than women [7; 8] and to be concentrated on men's crops and
tasks. Making extension available to women involves more than
training and motivating extension agents to address women
farmers' problems and their problems on the farm. It may involve
adding women extension agents on equal footing with male ones. It
also involves rethinking many of the means of communication used
in extension: scheduling public meetings at times convenient to
women, providing separate accommodations for women and child care
at residential training programmes, disseminating information
through channels accessible to women, and assessing women's
problems accurately and providing demonstrations for them [4].

Credit is less available to women, in part because it is often
channeled through extension agents and in part because women have
neither cash income nor collateral to put up as loan insurance.
Where loans to women have been made, their repayment rates are
usually better than men's [9]. Women's savings groups or
co-operatives are a promising means for women to qualify for
credit as long as they obtain the management skills and autonomy
required to maintain control of such organizations.

Usufruct rights to land are usually contingent on inheritance
or the continued goodwill of a man (household head, chief,
father, brother, husband, son), and, where agricultural
modernization and land value appreciation are rapid, usufruct
rights may be withdrawn or transferred to lower-quality or more
distant fields. Men's control of land extends to control of
cropping patterns. Henn [10] notes that in Cameroon and Tanzania,
men can prohibit women from growing cash crops on 'women's"
fields. The punishment a woman receives for disobeying her
husband can be divorce, physical abuse, or alienation from land.

Assuring women's secure access to clan or community land is
not easy to accomplish. Legal means often fail, and there is no
sure way to force households to increase women's land rights. It
is possible in resettlement schemes and through land-distribution
programmes to increase women's access to land, but the track
record there is abysmal.

Technology is also less available to women. On one hand, the
plough - the most widespread technical advance - is used
primarily by men and applicable to their tasks of clearing the
land and tilling. In fact, the plough can exacerbate women's
workload by allowing men to clear a larger parcel of land, which
women then have to cultivate without technological advances.
Agricultural research on women's crops, their farming methods,
and women's tasks (particularly weeding, transplanting, and
post-harvest processing) is also lacking [11]. Finally, women
usually lack the cash or credit to acquire the technology.
Moreover, when women's work is mechanized and monetized, it is
often taken over by men [3].

Examples of successful efforts to increase women's
agricultural productivity have been rare until recently because
ideology and reality have led more to criticism of existing
projects than to success stories. Some recent work [5; 9; 10],
however, has provided useful guidelines for successful
programmes.

In Peru a sheep-production project was unsuccessful when
it worked with a politically appointed all-male community
committee or with women's groups set up for other
purposes, but it flourished when it worked with an
all-female committee of sheep producers [11].

The agricultural extension system in Kenya has
successfully reached women through working with women's
savings societies [12].

In Cameroon, women farmers who lived close to a paved
road produced three times as much food as women not near
a road. Inaccessibility meant that women farmers in
remote areas not only had higher marketing costs but also
experienced direct conflicts with their husbands over
marketing [10].

In Kenya women used traditional rotating-credit societies
to buy tin roofs, with which they collected rainwater.
With the time saved (and some money earned from selling
water) they increased vegetable gardening and small-stock
production [13]

In the Gambia a women's onion production programme was so
successful that men asked to participate. Women refused
to work in their husband's garden plots, however, because
they were not adequately compensated, and so the men's
component failed [14].

A water-management project in Cape Verde benefited women
significantly even though it was not explicitly targeted
to women. The project, which built bunds, dikes, and
wells and reforested land in the catchment area, paid
women and men equal wages for this work, and every
household had to send one worker before any household
could send additional workers. This erased the
disadvantages faced by households headed by women [5].

Women agricultural labourers

The demand for paid agricultural labourers (often landless
women) has increased with the dissemination of high-yielding crop
varieties. In India, where over a third of the agricultural
labour force is female, women have not experienced a surge in
demand for their labour equivalent to that for men's labour in
the wake of the green revolution. In fact, women's wage rates
have fallen [15]. To have equal access to agricultural
employment, women must have access to new technology and
training: Agricultural research must take cognizance of the
demand for female labour by developing alternative cropping
systems and new plant varieties. Appropriate action should be
taken during testing and reproduction of new crops and
technologies to include women affirmatively.

Another opportunity for increasing female agricultural labour
productivity is through improving women's nutritional status, as
shown for tea pickers in Sri Lanka and Indonesia [16; 17].

Women's non-agricultural labour productivity

For women who earn income from non-agricultural activities,
increased returns for their labour are also possible. Many women
are involved in informal-sector activities, particularly market
sales, where margins are low and women have low returns for
labour [13; 18]. They are forced into the informal sector by
conflicts between formal-sector hours and household
responsibilities, by lack of education, and by frank sexism on
the part of employers [19].

While regulating change and upgrading market structures are
likely to facilitate better working conditions and profitability,
training and credit are likely to contribute more to
productivity. A recent US Agency for International Development
(USAID) evaluation found, in the Dominican Republic, that loans
to poor street vendors were successful because they are quickly
disbursed, did not require collateral, and were appropriately
small [9]. Women employed in the formal labour force are likely
to be better off than those in the informal sector and are more
likely to be young and unmarried; `'comparable-wage"
legislation is less likely to increase women's wages than to
exclude women from formal employment opportunities [19].
Educating women and enforcing anti-discrimination laws are more
likely to increase women's access to better paid and more
productive formal-sector employment over the longer term.

The exogenous introduction of women's income-generating
enterprises - often handicrafts or small livestock - has been
unsuccessful from an economic as well as a participation point of
view [9].

Reducing women's child-care burden

Mothers are the primary caretakers of children only in early
infancy [20]. Older siblings, grandparents, and members of the
extended household regularly care for preschool children even
when the mother is not employed outside the home. Children's
nutrition is often worse with non-maternal (particularly sibling)
caretakers [21; 22]. The quality of child care and the employment
conditions matter a great deal.

Several reviews of child-care programmes [23-26] show that
formal child care is available only to a minute proportion of
families. Instead, women rely on family or neighbourhood sources
of care. Myers and Indriso [23] point out that existing
child-care arrangements are usually good for either the child or
the mother but rarely for both. An optimal arrangement is
responsive to both generations' needs. Kin-based care is likely
to be convenient and affordable (the cost of sibling care in
terms of lost educational opportunities seems to be less salient
than its low out-of-pocket costs) but may be suboptimal for
children. Siblings provide certain kinds of mental stimulation
for children but often fail to provide reasonable-quality health
and nutrition care and infant-directed stimulation [22; 27]. New
child-to-child programmes are training children in health,
nutrition, and mental stimulation, but the participants are not
supposed to become full-time care givers [28].

Child-centred care consists largely of nursery schools
providing systematic mental stimulation, but often not for the
whole workday. Child-centred nutrition and health interventions
are usually of short duration and provide no psycho-social
stimulation or custodial care. Such programmes are not geared to
the hours or labour demands of working women because they end in
the middle of the workday or require the mother to attend with
her child. Optimal child care provides health and nutrition
services plus mental stimulation in a culturally acceptable,
convenient, and affordable way.

Myers and Indriso [23] provide several illustrations of such
child-care programmes:

- In India mobile crèches have been created at the work
site for women in casual construction labour. Care is
provided by lower-middle-class women from the location who
are specially trained by the umbrella private voluntary
organization project. The programme, which covers infants
through 12-year-olds, includes nutritious meals, health
surveillance, and mental stimulation or schooling, depending
on the child's age [24].
- In Salvador, Brazil, a non-traditional training programme
for women spun off a child-care programme as a required
adjunct to its primary activities. This programme enrolled
community women in a care givers' training course to teach
them about children's health, nutrition, and development and
gave them practical skills (e.g. making toys from local
materials) needed to run a day-care centre. The community
built a centre; the day-care trainees staffed it; and the
centre is heavily subscribed not only by the
training-programme participants but by the rest of the
community as well [29].
- Organized child care is not just an urban solution.
Seasonal and year-round child-care programmes in rural areas
have been successfully implemented in many countries. In
Senegal, seasonal agricultural demands had relegated small
children to inadequate care until a community day-care
programme was initiated. The programme includes feeding (the
food deriving in part from a community garden attached to the
centre and in part from in-kind fees) and custodial care.
Mothers rotate responsibility for the gardening and child
care. The programme is so successful it has been replicated
elsewhere in Senegal, and its scope has been expanded to
include other community development activities [23]. - An
Ethiopian fruit-growing co-operative instituted day care as a
co-operative venture to facilitate women's participation in
co-operative activities. Not only does the programme provide
custodial care, health care, and nutrition surveillance, but
women are given work credit for breast-feeding their infants
[23].

These and other examples provide consistent guidelines for
setting up day-care programmes: (1) they must be convenient for
women; (2) adequate training and supervision of day-care
providers are required to provide good quality care; and (3)
community fund-raising and participation, as well as outside
funding sources, are probably required, because costs of such
programmes - in facilities, equipment, training, and personnel -
often put them beyond the reach of the individual families that
need them most.

Increasing women's efficiency in home production

The third area in which there is potential for increasing
women's ability to carry out their nutritional responsibilities
is that of home production. Tasks in this category include
post-harvest agricultural processing, water and fuel-wood supply,
cooking, and cleaning; making soap, textiles, and pottery for use
by the household; and health and nutrition activities. If women
can save time or their own energy through increased efficiency in
this area, they can use the released resources to generate more
income, to rest, or to take better care of their children.

New technologies

"Appropriate technology" has often been proposed as
a solution to certain household production problems, but it has
rarely met expectations. The most prevalent target of appropriate
technology has been the time- and energy-intensive cleaning and
pounding of grain. In West Africa, grain milling, cassava
processing, and palm-oil extraction are all energy- and
time-consuming processes under women's control.

Efforts to introduce improved technologies in these areas must
be responsive to women's needs and technological control [30-32].

- In South Asia, activities such as winnowing, pounding,
and parboiling rice were traditionally carried out by women.
Although pounding grain is very time- and energy-intensive
and pure drudgery, it is a major source of income to the
poorest women in South Asia. Small mechanical mills run by
men have made great inroads into the grain-pounding business.
The new mills are far less expensive than human pounding, but
the social cost of the loss of income to poor women is high
[33; 34].
- In Upper Volta (now Burkina Faso) in the mid-1970s a
programme introduced grain mills, carts, and local wells,
which were supposed to alleviate the greatest time and energy
burdens on women - pounding grain and gathering fuel, wood,
and water [35; 36]. Yet about half the women did not use the
grain mills because of cost (even though a women's group had
established the price and had control of the millers). It was
suggested that women used the mills only when they were
forced to by illness or seasonally high work loads - when
their opportunity cost was higher. The carts intended to be
used for firewood gathering and water hauling were used by
only half the women, once again largely because of cost. The
wells were popular, but they went dry just at the point when
alternative sources of water were least accessible: hence
their time saving was minimal. Analysis of time use before
and after the introduction of these technologies showed,
however, that women did indeed gain time and that they
devoted it primarily to spinning cotton or (less frequently)
to rest.
- In Cameroon a corn mill which could be hand-operated by
women and significantly reduced the labour required for
milling proved successful. Loans, to be repaid by charging a
small fee for use, were made available for women's groups to
purchase the mills. The women were also trained in the use
and maintenance of the mills [37]. With the time released,
women attended classes in soap-making, cooking, and child
health.
- Soap production in Ghana has been greatly improved by a
private voluntary organization's commercial production of
ash. Women no longer need to burn large quantities of wood;
they just mix and cook the soap ingredients [37].

Home-based technologies need to be appropriate (solar cookers
should not require women to cook in the hot sun at midday, for
instance) and should not require large cash outlays; and women
should be provided with the training to maintain and repair them
[37]. Women, likely users of water pumps, are rarely trained in
their operation, maintenance, or repair. Moreover, poor women may
even lose income from the introduction of pumps: in Tanzania
women water carriers lost employment when water pumps were
introduced. In Kenya, on the other hand, women's self-help labour
was found to be more successful than paid male labour in the
construction and maintenance of dams and catchments; this success
was attributed to women's being the chief users of water and thus
having the knowledge and skills to maintain the water system [9].

Overall, technological solutions to women's household
production problems are likely to be more successful if women are
involved from project conception to execution, if they have
access to credit to procure the technology, and if they maintain
or gain control of the technology and resources transformed.

Health and nutrition activities

Another way to help women become more efficient in their
household production is through reducing the unnecessary burden
of sickness by teaching improved preventive health care, hygiene
practices, and food preparation. The development of
"instant" weaning foods is an excellent example. In
Nepal, a dry instant weaning food called sarbottam pitho can be
made in the home and reconstituted at the time of feeding to
avoid bacterial growth. It is superior nutritionally to the usual
"bacterial broth" and reportedly requires little extra
maternal time to make [38].

Reducing the time costs of food procurement and preparation is
important for the public and private food sectors. Bread is
probably the most widespread time-saving convenience food. It
requires no further processing, stores well, and can be eaten
throughout the day. Many developing countries artificially keep
the price of bread low because it has become a staple of the
urban poor. A study in Sri Lanka [39] found that, as women's wage
rates rose, the household consumed more bread and less rice.
Dried soups and pasta products are also very popular convenience
foods because they require very little preparation time and fit
in well with traditional foods and eating styles. Since
convenience foods are generally highly refined, they may lack
important nutrients found in more traditional foods. Whether the
benefits of convenience foods outweigh the costs is virtually
unknown. Street foods - often sold by women - are other
convenience foods that can save women time. These are precooked,
ready-to-eat foods sold in rural and urban areas, on streets as
well as house-to-house [40].

Improving women's health and nutrition

Historically, interest has focused on women's health and
nutrition largely because of their child-bearing and
child-rearing role and because women are at nutritional risk
because of reproduction. There is no question that improved
maternal health and nutrition directly improve foetal and
neonatal health. Much less is known about the impact of improved
maternal health and nutrition on women's successful fulfilment of
their other productive roles (though there have been some studies
- e.g. on Indonesian tea pickers [17] and Indian factory workers
[41]).

In addition to lacking information on women's productivity, we
are still very much in the dark on how to reach women with health
and nutrition programmes for their own good [42]. Women's
nutrition supplementation studies in Guatemala [43] and the
Gambia [44] have obtained good participation rates with
measurable improvements in anthropometric results for women and
children. (The Gambian women reported having more energy as a
result of these nutritional status improvements.)

- A CARE feeding programme in India found women more
likely to participate if the food ration was ready to eat and
women could pick it up on their way to the fields [45].
- A World Bank project in Indonesia induced women to eat
better diets through a nutrition education programme.
Behavioural trials determined that pregnant women were
willing to increase their total food intake slightly and to
eat more greens, but were unwilling to eat extra protein or a
great deal of additional food. Compliance with iron
supplements was good, and the negative side effects (of which
the women were forewarned) did not reduce compliance [46].
This Indonesian work demonstrates that women can be motivated
to improve their nutrition so long as it does not conflict
with firmly held beliefs.
- Efforts to increase the food intake of lactating women in
Indonesia met with success also, and several practices
(increased liquid intake and increased food) apparently
increased women's breast-milk supply as well. As a result,
some of them had to nurse their infants more frequently, but
they did not mind the extra work because their infants were
more content.
- The ICDS programme in India found that it obtained better
participation of lactating women and young infants if mother
and child were admitted as a unit (perhaps allowing the
mother to justify her attendance) and if both participants
were given food rations [45].
- Improving prenatal care by training traditional birth
attendants in the Philippines has improved care participation
rates [47].
- Use of supplementary feeding was associated with greater
tetanus toxoid coverage (and antenatal clinic attendance) in
India's Project Poshak [48].
- In the Philippines, Wong et al. [49] found that
accessibility (travel time) to prenatal care and availability
of health insurance strongly affected participation in
antenatal clinics, as did women's education.

Sustained participation of pregnant women in supplementary
feeding programmes is based on addressing the actual or perceived
risk of cephalopelvic disproportion that may cause women to
restrict food intake in late pregnancy [42; 50].

The consistent finding of these studies is that, to persuade
women to use health and nutrition services for themselves,
services must be made as cost-free as possible by making them
convenient geographically, minimizing the out-of-pocket and
opportunity costs of using them, and making them harmonious with
current beliefs and practices. In addition, women need the
authority or permission to seek help for themselves.

Combining interventions

To optimize the nutritional effectiveness of these programmes,
a combination of the elements discussed above is necessary. Women
cannot procure the benefits of household technologies or child
care without paying for them, but they are constrained from
increasing their income by the time demands of home production.
If women were healthier and nutritionally better off, they might
be more productive economically, but they have neither the time
nor the permission (possibly a function of their contribution to
household income) to eat more food or obtain health care for
themselves. Thus, complementary interventions are needed to break
the deadlock on women's resources for nutrition.

Research needs

Throughout the two parts of this article we have noted
information gaps and research needs. We summarize here the most
urgent issues requiring further research.

Women's nutrition

More information is needed on women's nutrition, food
consumption, and nutritional risks, especially changes in
nutritional status occurring over their reproductive lives [51].
In particular, the maternal depletion syndrome needs to be
investigated and the incidence of cephalopelvic disproportion
resulting from improved diet documented [50]. Better information
on the effect of improved nutrition on women's productivity in
the market and home is also needed.

Women's income

The impact of increases in women's income on the level of
allocation of food expenditures and on their own and other
household members' nutritional status needs further exploration.

Child care

The impact of formal and informal child care on women's
productivity, income, and reproductive behaviour, on children's
health and mental development, and on community child-care norms
and behaviours needs elaboration. Cost-effective and culturally
appropriate child-care mechanisms should be investigated in pilot
studies.

Househehold productivity

The effect of increased water and fuel-wood supply, reduced
food-processing time, and increased efficiency in post-harvest
food processing on women's income and nutrition, household food
security, and children's nutrition needs careful study. All too
little is known at present about household management skills and
productivity. Quantitative models of labour allocation and
household production need to be complemented with observational
studies to determine what women and their families need to know
and have to become more productive.

Operations research

Knowing what women need is one thing; delivering it to them
and even convincing them that they need it is quite another.
Research is needed along with service-delivery programmes in
agriculture, education, health, and nutrition to raise demand,
increase sustained participation, and enhance effectiveness. In
particular, we need new ways of creating the self-confidence
mothers need to adopt new behaviours and participate actively in
maternal-child health programmes.

Summary

Women play a major role in producing food, in generating
household income, in bearing and rearing children, and in overall
household production. Throughout their life cycles, poor women
experience role stress because of conflicting time, energy, and
economic demands made on them. The biological roles of pregnancy
and lactation often compete with physical labour for women's
nutrient intake and reserves. Women's economic activities compete
for their time with child care, home production, and other social
roles. Women may also find conflicts between their biological
needs and the ideal woman defined by culture. Their nutrient
needs may be belittled, their need for rest derided, their desire
that children should be widely spaced overridden.

Because poor women lack resources, these conflicts engender a
zero-sum game: any extra effort a woman devotes to one of her
roles (economic, biological, or social) detracts from her
fulfilment of other roles. Nowhere is this compromise more
apparent than in nutrition: women grow food, women's income buys
food, women prepare food and breast-feed, women's bodies nourish
the foetus and the suckling child, women use their physical
energy for work, and women are responsible for prevention and
treatment of most illness. To make a positive-sum game in
nutrition, women need to be able to increase their access to
food, reduce the nutritional costs of their role conflicts, and
enhance their control over nutrition-related resources.

The programmatic and policy implications of this situation are
that, to overcome these constraints, women need access to income
enhancement simultaneously with access to burden-reducing
services and technology. The existence of time lags before income
gains are realized implies that women need subsidies, credit, or
direct resource transfers during the transition in their income
potential. This transition period can be long (in the case of
education or institution building) or short (in the case of
credit). The most successful projects cited above minimized the
conflicts in women's financial responsibilities and time
commitments between family and market; provided child care along
with occupational training; provided health and child care along
with agricultural development efforts; provided for cost recovery
and credit along with grain mills. The most successful
programmes, in other words, respond simultaneously to women's
dual constraints - time and money.

A few key interventions stand out as central:

- promoting good child care through a combination of
regulation, training and technical assistance, institutional
development, and public subsidies to provide substitute child
care in rural and urban areas that will meet women's economic
needs and family responsibilities and children's need for
health care, nutrition, mental development, and
socialization;
- facilitating women's access to credit through institutional
development, supporting savings societies, changing banking
practices if necessary, and making loan size and procedures
appropriate for women;
- creating demand for women's health, nutrition, and
family-planning programmes and harmonizing delivery systems
and logistics with women's constraints;
- ensuring women's access to and control over technology and
other productive resources through research and development,
targeting, training, marketing, and credit.

Child-survival technology can be a powerful tool enabling
women to meet productive and family responsibilities better, but
the costs of participation must be appropriate to the resources
available to women.

Interventions in these areas promise to help women break out
of their time, money, and energy constraints. They create
opportunities for a positive increase in available time and
energy resources that can improve the nutritional status of
women.

Acknowledgements

We thank the Advisory Group on Nutrition of the ACC/SCN, Dr.
Abraham Horwitz, and Dr. John Mason for their encouragement and
advice in all phases of the development of this overview article.
We thank the ACC/SCN for providing financial support for its
preparation. We thank Martha Burdick, Samya Burney, Patricia
Dargent, Lionel Deang, and Anna Viggh for research assistance. We
also thank Linda Adair, Corazon Barba, and Chloe O'Gara for
comments on earlier drafts. We thank Lynn Moody Igoe, Frances
Dancy, Catheryn Brandon, Mary Ann Daly, and Ealise Crumb for
editorial and secretarial assistance. None of these persons is
responsible for the final views presented here.

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